Experiences of Transgender and Gender Expansive Physicians

Key Points Question What are the professional experiences of US physicians who are transgender and/or gender expansive (TGE)? Findings In this qualitative study of 24 physicians who identify as TGE, major themes emerged centering on emotional distress associated with overt and subtle transphobia throughout the spectrum of medical training and practice. A need for structural and interpersonal changes to improve physicians’ understanding of gender diverse individuals and promote workplace inclusivity was identified, with specific examples of mitigation strategies. Meaning These findings signal a need for institutions and individuals to engage with strategies to target transphobia and gender biases in the health care setting.

This supplementary material has been provided by the authors to give readers additional information about their work. eTable 1. Glossary of Terms Assigned gender at birth (AGAB) A recorded gender (gender represented by various legal or other institutions/systems) generally indicated by the gender on the birth certificate. 1

Gender
Gender comprises the social, environmental, cultural, and behavioral factors and choices that influence a person's self-identity Gender identity An individual's sense of belonging to a gender category as male, female, a blend of both, neither, or another gender and is comprised of both biological and sociological elements 1 Gender expression The external manifestation of categorized gender norms based on sociocultural context (appearance, dress, and behavior) 1,2 Cisgender A term used to describe a person whose gender identity aligns with those typically associated with the AGAB Transgender An umbrella for people whose gender identity and/or expression is different than the cultural expectations based on their AGAB and may include gender nonbinary, gender nonconforming, or genderqueer identities. 3 Note: being transgender does not imply a specific sexual orientation. Transgender woman Typically used to describe a woman who was assigned male at birth Transgender man Typically used to describe a man who was assigned female at birth Non-binary This is an umbrella term used for gender identities outside of the gender binary (man/woman) but does not mean the same as "intersex". Individuals who identify as non-binary may identify as an intermediate or separate gender, identify with more than one gender or have fluctuating gender identity (genderfluid), or identify as agender. Some, but not all, individuals who identify as non-binary classify themselves as transgender. 4 Genderqueer A person who blurs preconceived binary gender boundaries and may identify as a combination of gender, neither, or both. 3

Gender expansive
An umbrella term encompassing individuals and gender identities that may exist beyond the binary framework (e.g. may include non-binary, genderqueer, agender) 5 Coming out The process of disclosure of gender identity to oneself and/or others. There are degrees of being out (to self/social circles/professionally), and coming out is a personal, lifelong process. 3

Transition
This term refers to the process a transgender individual goes through to affirm their gender identity and may occur in social, legal, and/or medical realms. The process of transitioning may include some of the following: changing names / pronouns / identification documents, as well as hormones and/or surgeries. Not everyone who identifies as transgender will undergo transition, or chose to transition in the same ways (e.g. hormone therapy, surgery, etc) 3 Passing A term used to describe when someone is perceived as their correct gender and gender-typical / cisgender. 3

Stealth
A term used to describe transgender or gender-expansive individuals who maintain their privacy and do not disclose (similar to passing). 3

Gender affirming care
Health care that attends to transgender individual's physical, mental, and social health needs and well-being while respectfully affirming their gender identity Misgendering To refer to someone using a word, especially a pronoun or form of address, which does not correctly reflect their gender. This may be unintentional and without ill intent or can be a maliciously employed expression of bias. Regardless of intent, misgendering has a harmful impact. 3 Deadname A term used by some transgender individuals to refer to their pre-transition or precoming out name which is often, but not always, the name which appears on their original birth certificate (i.e.birth name or "assigned name"). Deadnaming is the practice of referring to an individual by their deadname and is considered a form of abuse. 1

eMethods. Interview Guide
Interview Guide Thank you so much for agreeing to participate in this interview. We are conducting a study of the professional experiences of emergency physicians who identify as transgender a-nd/or non-binary. We are going to ask questions about biases, gender biases, and transphobia in the workplace. Please skip any questions you don't want to answer. You can also ask to stop the interview at any time. As mentioned previously, all information will be de-identified and in no way linked to you.
To help us understand the intersection of your experiences with gender and your professional career, it would be helpful to hear a bit about your gender identity and how you currently present at work. To ensure the findings are repeatable within the same cohort of participants, coders, and context Rich description of the study methods: We created a detailed draft of the study protocol

Confirmability
To extend confidence that the results were derived from the data and would be confirmed by other researchers Reflexivity: Although our study team was comprised of women emergency physicians/trainees and one student, we included investigators who are members of the LGBTQIA+ community and not, and members across the spectrum of training/career. We also reported research positions and demographics in the manuscript. Triangulation: We triangulated sources and examined the consistency of individuals with different backgrounds, gender identities, and specialties Transferability To extend the generalizability or transferability of results to other contexts/settings Sampling to form a nominated sample: We used a combination of sampling techniques (recruited via social media, list servs, and by word of mouth). Data Saturation: We identified when we reached theoretical data saturation and extended interviews to reach demographic saturation targets (gender identity / region of United States) Thick description: we used probes in the semi-structured interviews to enhance description